IELTS Request for Refund or Test Date Transfer Form + Personal details Tie ie Giennanes: CHgauy Hes Mah sumane: (“Magu pasuess De AE Vian Wag, REO CIT cine uci We, WH Telophone: 0ap9222 1D Ema ~ Testdaterogisteadion . Request is for (tick one box) une jale Transfer We can process @ refund payment via bank transfer only. et eceee eee La lome eee Pesrepovaeyouton dear knee cantenanenunber: [ayy ma oe Preerod new est dae 5° 7 aw DORE Bank trac rE Ploase select the test that you registered for: Bank account nurrer © \eLTS\Paper Based) 0 Computer-delvered LTS Boneficlay’s Naf: 11 IELTS for UKWI (Paper Based) 0 IELTS for UKWI (Computer-delivered) © Life Skis At Ute Skills 2 0 Life Sills B1 Please select the test that you wish to transfer to : repented) 0 CorvsrdeiendaTa HLTE hy Usted ui Candidate statement (to be completed by tho candidato) Please dota your grounds for applying fora relund or atest date ans on {n caso of modal reasons, this form must be accompanied by an original medical cortiticate issued by a Professional Medical Practitioner. The medical ertficate must include nature of illness and other relovant informaton ha (ith reference to the candidate's capacity to sitan exam) which willagsistin any assessment of tis applVealion or on special consideration Forother reasons, please attach relevant documentation/evidence (palice report, military service notice, death notice) - (attach oxra sheet ere sinsuicientspaco), Lost Ppasspork omc nek (a aoe a ten The Information on ths form Ts collected for the primary purpose of assessing your request for a refunditest — date transfer. Ifyou choose not to completo all tho questions on this form, tmayangt bagnossible for tho test centro to process your reves. 2 Ccandidatesignatue tamatte = ow: (edo) Received by: ‘ Date: = Test centro use only: Request (please select: APPROVED NOT APPROVED ‘Authorised by: (IELTS Administrator = March 2020 Date: